American Journal of Occupational Therapy

Programs and concepts included in the Patient Protection and Affordable Care Act of 2010 are expected to transform health care in the United States from a volume-based health system to a value-based health system with increased emphasis on prevention and health promotion. The Triple Aim, a framework set forth by the Institute for Healthcare Improvement, focuses on improving the health care experience, the health of populations, and the affordability of care. This article describes telehealth as an integral component in achieving the Triple Aim of health care and discusses implications for occupational therapy practitioners.

OBJECTIVE. To investigate the effects of a 17-mo initiative designed to increase practitioners’ knowledge and skills related to evidence-based practice (EBP) in the schools.

METHOD. We evaluated participants’ EBP knowledge and skills at pretest and posttest using the Adapted Fresno Test (AFT) and collected their perceptions through a survey.

RESULTS. Participants demonstrated significant improvements in their EBP knowledge and skills after participating in this initiative as measured by changes in AFT scores. A significant difference was noted in scores between pretest (μ = 43.9, SD = 32.67) and posttest (μ = 74.66, SD = 33.99), t(28) = −5.645, p < .001.

CONCLUSION. This initiative was influential in increasing school-based practitioners’ EBP knowledge and skills.

OBJECTIVE. We used a randomized controlled design to investigate whether using stability balls during the school day was associated with higher levels of on-task behavior and academic achievement and fewer discipline referrals.

METHOD. Over 9 mo, students in 2 second-grade classrooms in a southeastern rural elementary school used stability balls as chairs while students in 2 control classrooms used chairs as usual. We collected measures of on-task behavior, standardized measures of literacy and mathematics achievement, and discipline referrals.

RESULTS. We found similar levels of on-task behavior and achievement in treatment and control classrooms and a downward trend in disruptive behaviors in treatment classrooms.

CONCLUSION. This study did not find use of stability balls for entire general education classrooms to be a practical use of resources for schools. More research with rigorous controlled designs is needed to support the use of stability balls for the general education population.

OBJECTIVE. We developed a comprehensive social skills taxonomy based on archived children’s social skill goal sheets, and we applied the taxonomy to 6,897 goals of children in 6 diagnostic categories to explore patterns related to diagnosis.

METHOD. We used a grounded theory approach to code and analyze social skill goals and develop the taxonomy. Multivariate analysis of variance and Tukey post hoc honestly significant difference test were used to analyze differences in social skill needs among diagnostic groups.

RESULTS. We developed a taxonomy of 7 social skill constructs or categories, descriptions, and behavioral indicators. The 7 social skill categories were reflected across 6 diagnostic groups, and differences in social skill needs among groups were identified.

CONCLUSION. This comprehensive taxonomy of social skills can be useful in developing research-based individual, group, or institutional programming to improve social skills.

Research has demonstrated the importance of beliefs about knowledge and knowing, or epistemic and ontological cognition (EOC), to learning and achievement; however, little research has examined occupational therapy students’ EOC or determined whether occupational therapy programs promote its development. This study examined changes in EOC over 18 mo of didactic coursework in an occupational therapy program. Thirty-one students completed the Epistemic Beliefs Inventory at the beginning, middle, and end of 18 mo of didactic coursework. Results indicated no difference in ontological cognition. However, change occurred in epistemic cognition, with students demonstrating statistically significantly weaker beliefs in justification of knowledge by an omniscient authority by the end of the didactic portion of the program. Although causal inferences cannot be made from this small study of one cohort of occupational therapy students, it is possible that intensive study in the discipline of occupational therapy contributed to change in these students’ epistemic cognition.

OBJECTIVE. Reduced physical fitness secondary to heart failure (HF) may contribute to poor driving; reduced physical fitness is a known correlate of cognitive impairment and has been associated with decreased independence in driving. No study has examined the associations among physical fitness, cognition, and driving performance in people with HF.

METHOD. Eighteen people with HF completed a physical fitness assessment, a cognitive test battery, and a validated driving simulator scenario.

RESULTS. Partial correlations showed that poorer physical fitness was correlated with more collisions and stop signs missed and lower scores on a composite score of attention, executive function, and psychomotor speed. Cognitive dysfunction predicted reduced driving simulation performance.

CONCLUSION. Reduced physical fitness in participants with HF was associated with worse simulated driving, possibly because of cognitive dysfunction. Larger studies using on-road testing are needed to confirm our findings and identify clinical interventions to maximize safe driving.

We examined the variables most associated with activity limitation (i.e., cooking) and participation restriction (i.e., employment) in 72 people with multiple sclerosis (MS). Participants underwent a comprehensive neuropsychological test battery assessing memory, executive functions, visual perception, and processing speed and completed questionnaires assessing activity, participation, fatigue, and affective symptoms. Results showed that processing speed was the only variable consistently significantly related to both activity and participation. When examining specific aspects of activity and participation in isolation, employment status was significantly associated with education level, visual memory, fatigue, and processing speed. Cooking ability was associated with performance on tasks of working memory, verbal memory, and processing speed. These findings suggest that processing speed is a primary cognitive factor in MS influencing quality of both activity and participation in everyday life.

Sexuality and intimacy are important components of health and well-being. Issues surrounding sexuality and intimacy are equally important for men and women living with physical disabilities, including spinal cord injury (SCI). Yet, women’s sexuality after SCI remains largely unexamined. This article presents the findings from an in-depth qualitative investigation of the sexual and reproductive health experiences of 20 women with SCI in or around Detroit, MI. Findings echo existing literature documenting the sexual consequences of life after SCI and suggest new areas of inquiry important for better addressing sexual concerns across the lifespan. Specifically, findings suggest a need to consider the variable effects of SCI on sexual intimacy in relation to a person’s developmental trajectory, the appropriate timing of sexual education, the need to expand conceptualizations of sexual intimacy, and the ways SCI may affect sexuality in later life.

OBJECTIVE. We present a novel, knowledge-driven approach to prescription of pointing devices that uses the Ontology-Supported Computerized Assistive Technology Recommender (OSCAR), a clinical decision support system (CDSS).

METHOD. Fifty-five occupational therapists were divided into four groups: two assistive technology (AT) expert groups and two novice groups. Novice Group 1 used the OSCAR CDSS for the prescription process, and Novice Group 2 used the conventional method. OSCAR’s effectiveness and its impact on users were evaluated.

RESULTS. The ability of Novice Group 1 to make suitable pointing device prescriptions was similar to that of the two expert groups and was significantly better than that of Novice Group 2. The system positively affected Novice Group 1’s learning of the prescription process.

CONCLUSION. The structure and organized framework for clinical reasoning of the OSCAR CDSS appear to enable occupational therapy practitioners inexperienced in AT to achieve performance levels comparable to those of experts.

Data on the utilization of occupational therapy among patients with brain tumors have been limited to those with malignant tumors and small samples of patients outside North America in specialized palliative care settings. We built on this research by examining the characteristics of patients with brain tumors who received postacute occupational therapy services in Ontario, Canada, using health care administrative data. Between fiscal years 2004–2005 and 2008–2009, 3,199 patients with brain tumors received occupational therapy services in the home care setting after hospital discharge; 12.4% had benign brain tumors, 78.2% had malignant brain tumors, and 9.4% had unspecified brain tumors. However, patients with benign brain tumors were older (mean age = 63.3 yr), and a higher percentage were female (65.2%). More than 90% of patients received in-home occupational therapy services. Additional research is needed to examine the significance of these differences and to identify factors that influence access to occupational therapy services in the home care setting.

OBJECTIVE. The aim of this study was to determine the effects of home-based robot-assisted rehabilitation coupled with a home exercise program compared with a home exercise program alone on depression and quality of life in people after stroke.

METHOD. A multisite randomized controlled clinical trial was completed with 99 people <6 mo after stroke who had limited access to formal therapy. Participants were randomized into one of two groups, (1) a home exercise program or (2) a robot-assisted therapy + home exercise program, and participated in an 8-wk home intervention.

RESULTS. We observed statistically significant changes in all but one domain on the Stroke Impact Scale and the Center for Epidemiologic Studies Depression Scale for both groups.

CONCLUSION. A robot-assisted intervention coupled with a home exercise program and a home exercise program alone administered using a telerehabilitation model may be valuable approaches to improving quality of life and depression in people after stroke.

OBJECTIVE. The objective of this study was to develop and validate a clinical reasoning tool to describe an occupational therapist’s clinical reasoning process while delivering home modification interventions.

METHOD. We used a two-phase, mixed-methods approach. In Phase 1, we developed a personal factors guideline to support clinical reasoning in home modification interventions based on in-depth interviews, a focus group, and field observations of 6 home modification experts. In Phase 2, the guideline was validated by a second group of 6 home modification experts.

RESULTS. During analysis, 16 personal and environmental factors with a corresponding set of conditions and strategies for each factor emerged to form a clinical reasoning guideline, which was validated by a second group of experts.

CONCLUSION. Unpacking the “black box” of the clinical reasoning process has yielded a useful clinical reasoning tool that will allow occupational therapists to deliver complex interventions with fidelity.

Tilt-in-space (TIS) wheelchairs are common in residential care, but little empirical evidence exists regarding how they are used by residents and staff in these settings. As part of a larger study exploring the use of wheeled mobility in these facilities, we conducted a substudy to examine how TIS wheelchairs are used in practice and to explore the experiences of the residents who use them. We conducted a series of three participant observations and interviews with 6 residents or their family members and interviewed 10 staff. Our analysis identified taking control as the main overarching theme, subsuming two subthemes: promoting comfort and mobilizing to participate. Findings suggest that power TIS wheelchairs enable user control, whereas manual TIS wheelchairs promote staff control. These findings illustrate how TIS wheelchairs may enable or inhibit occupational engagement and suggest that vigilance is necessary to prevent their use as a restraint.

OBJECTIVE. Little is known about how visuospatial deficits affect the use of electronic devices operated by pressing spatially interspersed buttons. This study aimed to determine whether people with Bálint syndrome can effectively use such devices.

METHOD. We quantified the ability of 7 study participants with Bálint syndrome to use button-operated electronic devices by measuring the time required to input digit sequences into three different types of devices. Control groups were 8 participants with amnesia and 8 healthy participants.

RESULTS. Participants with Bálint syndrome took longer to input a digit sequence on all three devices than did those in the two control groups. Although we found no significant differences with respect to type of device, 2 of 3 participants with severe Bálint syndrome were able to input one- to five-digit sequences with the electronic calculator.

CONCLUSION. Distinctive design features might positively affect the performance of people with Bálint syndrome.

We examined the test–retest reliability of the Child Occupational Self-Assessment (COSA). Fifty-two children ages 6–12 yr completed the COSA on two separate occasions 7–14 days apart. Participant data were analyzed using intraclass correlation coefficients (ICCs). Test–retest reliability was good for total Competence and Value scores (ICC_2,1 = .72–.77) and poor to good across category scores (ICC_2,1 = .44–.78). These findings suggest that the children’s perceptions of their abilities and the value they placed on their everyday activities as reflected in the test items were fairly consistent over a short period of time.

The Record of Driving Errors (RODE) is a novel standardized tool designed to quantitatively document the specific types of driving errors that occur during a standardized performance-based road test. The purpose of this study was to determine interrater reliability between two occupational therapy driver rehabilitation specialists who quantitatively scored specific driving errors using the RODE in a sample of older adults diagnosed with dementia (n = 24). Intraclass correlation coefficients of major driving error and intervention categories indicated almost perfect agreement between raters. Using raters with adequate training and similar professional backgrounds, it is possible to have good interrater reliability using the RODE on a standardized road test.

OBJECTIVE. This article describes how adolescents with sickle cell disease (SCD) perceive their ability to perform everyday tasks required for transition to adult health care and independent living.

METHOD. The Adolescent Autonomy Checklist (AAC) was adapted to include skills associated with managing SCD (AAC–SCD) and was administered to adolescents during clinic visits. Participants indicated “can do already” or “needs practice” for 100 activities in 12 categories.

RESULTS. Of 122 patients, the percentage of adolescents who needed practice was greatest in living arrangements (38.7%), money management (35.8%), vocational skills (29.6%), and health care skills (25.5%). We found a significant effect of age and of cerebrovascular injury on the percentage of those who reported “needs practice” in multiple categories. We found no effect of gender and limited effect of hemoglobin phenotype on any skill category.

CONCLUSION. Findings support the need for educational intervention to improve transition skills in adolescents with SCD.

To realize the American Occupational Therapy Association’s Centennial Vision, occupational therapy practitioners must embrace practices that are not only evidence based but also systematic, theoretically grounded, and driven by data related to outcomes. This article presents a framework, the Data-Driven Decision Making (DDDM) process, to guide clinicians’ occupational therapy practice using systematic clinical reasoning with a focus on data. Examples are provided of DDDM in pediatrics and adult rehabilitation to guide practitioners in using data-driven practices to create evidence for occupational therapy.